Current opinion in anaesthesiology
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Investigate the rational for incorporation of regional anesthesia techniques into a multimodal approach toward patients with co-existing chronic pain as increasing numbers of chronic pain patients are presenting for surgery. ⋯ The systemic condition of chronic pain has important practical and clinical implications for regional anesthesia implementation by anesthesiologists and pain management physicians. Comprehensive preadmission assessment together with a complete medication history and close follow-up management should always be employed in patients with pre-existing chronic pain throughout the perioperative setting. Despite successful implementation of neural blockade, and to avoid opioid withdrawal, at least half the chronic pain patient's daily pre-admission opioid dose should be continued daily throughout the perioperative period. Regional anesthesia is a preferable anesthetic option for perioperative management technique of patients with co-existing chronic pain, even if it requires supplementation with sedation or general anesthesia. The specifics of regional anesthesia performance and practical strategies for regional anesthesia application in chronic pain patients, including implanted pain management devices, are reviewed in this study.
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Curr Opin Anaesthesiol · Oct 2010
ReviewAntiepileptic drug therapy in the perioperative course of neurosurgical patients.
Antiepileptic agents are widely used in the perioperative course of neurosurgical patients - for prophylactic and therapeutic reasons. However, the evidence supporting their use is extremely small and adverse events are common. This review highlights the current controversies. ⋯ Despite lacking evidence, prophylactic antiepileptic drug use is common in the perioperative course of neurosurgical patients. More research is needed to deal better with epileptogenesis and to define the right drug for the right patient at the right time.
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Curr Opin Anaesthesiol · Oct 2010
ReviewIndications and management of continuous infusion of local anesthetics at home.
The review examines recent research activity in the field of continuous peripheral nerve blocks in the ambulatory setting and places it in context with regard to previous research efforts. ⋯ Continuous peripheral nerve blockade at home offers good short-term control of postoperative pain in the outpatient setting. Long-term outcomes remain to be evaluated fully. More information is becoming available on local anesthetic volume and concentration relationships in both the upper and lower extremities--optimal strategies are not yet clear. Ultrasound may offer benefits in terms of speed and ease of continuous catheter placement while reducing the necessary number of needle passes required to reach the target structure site(s).
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Curr Opin Anaesthesiol · Oct 2010
ReviewGlucose management in the neurosurgical patient: are we yet any closer?
This review focuses on recent findings in perioperative management of blood glucose control using intensive insulin therapy in neurosurgical and neurocritical care and in other intensive care unit patients. We also aim to address practical issues and make recommendations that may contribute to the safe clinical application of intensive insulin therapy targeted to optimize blood glucose control in these patients. ⋯ In neurosurgical and neurocritical care as well as other intensive care unit patients, both hypoglycemia and hyperglycemia have significant adverse effects. The optimal glucose level remains under debate but significant steps have evolved with the call for judicious control and elimination of the historical approach to glycemic management, which underestimated drawbacks associated with dysglycemia. The increased incidence of hypoglycemia and mortality as well as the impact of hyperglycemia on worsening neurologic function in patients with acute brain damage heightens the need for more clinical studies on perioperative glucose management in these patients.
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Curr Opin Anaesthesiol · Oct 2010
ReviewCurrent concepts and future trends in ultrasound-guided regional anesthesia.
Ultrasound guidance for regional anesthesia has gained enormous popularity during the past several years. This review article highlights the importance of acquiring an understanding and knowledge of human anatomy for well tolerated and effective performance of regional anesthesia; includes description of some of the major principles of ultrasound-guided regional anesthesia techniques (adequate identification of neuronal and adjacent anatomical structures along with the procedure needle); use of adequate volumes of local anesthetic and the proper administration of local anesthetic; and discusses economical along with educational aspects of ultrasound-guided regional blocks. ⋯ With little reservation, it is anticipated that ultrasound-guided regional anesthesia will become the 'GOLD' standard for performance of regional anesthesia. Excellent science and educational concepts will continue to be required with the continued increase in popularity of this exciting specialty of anesthesia.